Dear Alistair

I must admit there are aspects of this debate I was hoping to lay to rest,
simply because I felt it was not going anywhere new. I am happy however to
respond to your recent questions.

Firstly I have the luck of working closely with the prescribers of the
medication; thus aiding co operation between clinicians in the prescription
process. All parties, physio, patient and GP see analgesic reduction as a
desireable goal; in the vast majority of cases. The reasons for success are
likely to be a combination of all three points you raise.

The success I have with chronics is when using an approach in physiotherapy
terms, which had not been tried to date. To make a sweeping statement like,
physio has not worked for this patient tells us little. Was it a junior
inexperienced physio, were the work circumstances more akin to processing
rather than treatment etc. Therefore sometimes we need to look to the
delivery of and not pander to the insecurities of a profession which clearly
can never have a 100% success record. If I did I would be in a church not a
physio clinic. I saw this at the beginning of the debate with the 'look at
all your failures' routine.

Recently I treat a chronic back problem. Eliminated all the reported pain
and increased ROM and function to full and reduced analgesics to zero. She
was seen 3 times and had a manipulative treatment not previously tried. All
decent physios do this on a regular basis and this is not peculiar to me.

I did not use any overt psycho/behavioural approach although many are saying
this is the only likely to work. These experiences are also common and not
one offs.
In chronic pain there are clear psycho/behavioural triats but are these
causing the 'illness' or a descriptor of it. Ie change the physical reason
(where possible) for the complaint and the behavioural/psychological
indicators will reduce reciprically.

There are clearly a percentage of patients who need a purely psychological
approach. I believe this percentage is drastically smaller than the figures
that are being touted at present. If this is the case we are in danger of
labelling and pathologiseing groups of people with diagnoses which are
almost impossible to disprove or reverse when the clinician has got it
wrong. Perhaps and this is a big perhaps physios should practice these
skills without formal recogniton in a similar fashion to placebo.

Another worrying factor is that in this country we are meant to tell our
patients the reasons and background to our assessment, ask for their
permission and give them options where possible. The public will see a visit
to a physiotherapist as an encounter with physical properties. If this
encounter takes the shape of an almost complete
psychological/assessment/counselling, how do we brouch this issue?.

Using the Gifford layered analogy I have as much interest in retraining as a
psychologist as I do a pharmacist, genetist, OT or politician. All have a
serious impact on our work and a similar case could be made for each.

It will take me a lifetime to become competent at most of the aspects of
manual therapy/rehabilitative exercise.

I am now bracing myself        Regards Kevin




-----Original Message-----
From: alistair grant <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 13 March 2000 12:27
Subject: Re: spinal psychology


>Thanks Kev; Glad to see you are still up to mischief!
>
>I'm interested to hear that you would hope for a 100% reduction; is this
>what you also actually experience clinically?
>
>If so, who influences this most? In your experience is it:-
>i) the patient wanting to reduce opioids or feeling confident that they can
>reduce consumption when they are under physio treatment
>ii) the therapist's influence either directly by recording and titrating
>analgesics accordingly or indirectly by asking about analgesic consumption
>in their assessment
>or
>iii) other influences such as GP or specialist, family etc?
>
>Also am I right in believing there is no recommended guidelines or protocol
>for weaning patients off opioids if they happen to be chronic users for low
>back pain? (This of course implies that opioids should be weaned for
chronic
>back pain which is the scenario I am specifically looking at before
mailbase
>gets 100's of replies stating this is not necessarily the situation in
every
>patient with LBP!!!)
>
>As you have gathered from your later e-mail to Jill I am interested in the
>process of opioid prescription and consumption rather than the efficacy of
>physio treatment although of course there is interplay between them!
>
>Say hello to Michelle and anyone else up in the frozen North!
>Hold you to that beer next time I'm up
>
>Alistair
>
>>From: "kevin reese" <[log in to unmask]>
>>Reply-To: [log in to unmask]
>>To: <[log in to unmask]>
>>Subject: Re: spinal psychology
>>Date: Fri, 10 Mar 2000 16:39:52 -0000
>>
>>Dear Ali
>>
>>Yes the one and the same, presently working with Michelle.
>>
>>In a successful case I would hope for a 100% reduction in analgesia, noted
>>as a progressive wheening off of the medication. Sometimes an important
>>period in rehabilitation to normalise the patients responses and re
eduvate
>>regarding damaging and non damaging stimuli.
>>
>>Let us know when your next up NE and we'll have a beer or twelve.
>>
>>Regards Kevin
>>-----Original Message-----
>>From: alistair grant <[log in to unmask]>
>>To: [log in to unmask] <[log in to unmask]>
>>Date: 10 March 2000 14:29
>>Subject: Re: spinal psychology
>>
>>
>> >Surely not Kevin Reese infamous at 1990-1993 University of Northumbria
at
>> >Newcastle???
>> >
>> >Anyhow I have been fascinated by this ongoing debate concerning manual
>> >therapy approaches and the pro's and con's of differing models in the
>> >management of low back pain. I wonder if all this energy could be
>>harnessed
>> >in helping me (as a non-specialist respiratory physio!) answer two
>>questions
>> >for a proposed research trial of opioids in chronic pain:
>> >
>> >The specific questions are:-
>> >
>> >1)What might be the anticipated average reduction in the patients
>>analgesic
>> >consumption when physiotherapy is "effective" (i.e. any favourable
>>response)
>> >in the management of chronic back pain?
>> >
>> >2)How would this be measured and interpreted clinically (if at all)?
>> >
>> >Hope somebody might have a measure on this.
>> >
>> >In anticipation!
>> >
>> >Alistair Grant
>> >
>> >
>> >>From: "kevin reese" <[log in to unmask]>
>> >>Reply-To: [log in to unmask]
>> >>To: <[log in to unmask]>
>> >>Subject: Re: spinal psychology
>> >>Date: Tue, 7 Mar 2000 18:56:24 -0000
>> >>
>> >>Dear Ian
>> >>
>> >>By far the most sensible answer on this topic to date. You neither
imply
>> >>that these points have been proven (philosophically is this possible)
or
>>we
>> >>ditch our traditional skills after 3/52.
>> >>
>> >>Giffords 10 minute, 1999 CSP Conference presentation was head and
>>shoulders
>> >>the best. The layered analagies for genetisist to politician is exactly
>>the
>> >>the right conceptualisation of pain in my view. We can all alter a
>>window
>> >>in
>> >>the greater picture, should have a good awareness of the other factors
>> >>influencing pain, but realise our strengths.
>> >>
>> >>I feel we can present lots of evidence for and against most issues and
I
>> >>think previous fads in physio like MET and MB are being replaced by the
>> >>psychosocial approach; perhaps the most recent fad.
>> >>
>> >>Nice reply and I'll shut up for a bit.   Regards Kevin
>> >>
>> >>
>> >>-----Original Message-----
>> >>From: Ian & Colette Stevens <[log in to unmask]>
>> >>To: [log in to unmask] <[log in to unmask]>
>> >>Date: 07 March 2000 14:05
>> >>Subject: Re: spinal psychology
>> >>
>> >>
>> >> >Kevin,
>> >> >
>> >> >I have replied to this on two occasions but owing to little hands my
>> >>replies
>> >> >got deleted !
>> >> >
>> >> >However briefly to an altogether complex multifaceted problem Kevin I
>> >>will
>> >> >offer some thoughts ......
>> >> >
>> >> >Using a  different model for the assessment of psychological V's
>>physical
>> >> >dysfunction may be worthwhile and make one aware of the complexities
>>and
>> >> >multifaceted nature of the person before you. Wherever possible I try
>>to
>> >>use
>> >> >Louis MOM approach, analysed from this perspective the model may
serve
>>to
>> >> >minimise dualistic  interpretations of facet/imbalance or whatever
>>else
>> >>is
>> >> >in vogue in physio circles V's supratentorial ...
>> >> >
>> >> >However with this in mind it is certainly advisable for a person
>> >>interested
>> >> >in manual therapy to be aware of the issues outside their
>>interpretation
>> >>of
>> >> >physical dysfunction .... It is so easy to search endlessly for a
>>tissue
>> >> >based solution to explain benign low back or for that matter
>> >>cervicobrachial
>> >> >pain before the patient trundles off somewhere else or ends up at a
>>pain
>> >> >management clinic .
>> >> >If the literature is to be believed and my clinical practice
certainly
>> >> >reflected this, Kendalls work on yellow flags for poor outcome should
>>be
>> >> >widely disseminated .
>> >> >Simple questions on presentation should be what do you think is
wrong
>> >>with
>> >> >you ? If you give a purely mechanical structural answer or solution
>>many
>> >> >people will become disabled .... which is exactly what has happened
>>read
>> >> >Zussmanns excellent essay, Waddells back pain revolution or ask
>>patients
>> >> >what they were told ......
>> >> >However this again is a complex issue as many people obviously
respond
>>to
>> >> >the analogies of things being pushed in and out and some therapists
>>make
>> >>a
>> >> >fortune doing and telling people this ( depends who is doing the
>>probing/
>> >> >how expensive/ distance travelled and impressiveness etc etc)....
>> >> >Additionally as a culture the usual response is to treat ones body
>>like
>>a
>> >> >car and the  intervention is usually analysed in this fashion too ---
>>in
>> >> >grey areas like musculoskeletal pain the intervention certainly is
not
>> >> >simplistic as we all know ....but people like simple solutions to
>>complex
>> >> >problems therapists/patients alike...
>> >> >
>> >> >We should as a profession be much more aware of the complex
>>interaction
>> >>as
>> >> >people becoming disabled with benign 'mechanical' problems are
>>increasing
>> >> >not reducing in number ?
>> >> >However this requires in many instances a shift to happen in
>>therapists
>> >> >education and the issues associated with musuloskeletal  pain to be
>> >>better
>> >> >understood or at least be valued ......This doesn't mean being a
>> >> >psychologist but often a subtle shift in intention during treatment
>>not
>> >> >slotting people into boxes because they fit into categories who may
or
>> >>may
>> >> >not  become chronically disabled.....
>> >> >If the epiemiology  statistics were to be believed no patient in my
>>last
>> >> >place of employment would have got better at all ( poorest health in
>>UK,
>> >> >massive unemployment, little if any place of leisure , and family
>> >> >dysfunction++ typical of many nhs deepest in inner cities I am sure).
>> >> >
>> >> >It does have to be said that depts as above do need multidisciplinary
>> >>teams
>> >> >to have a chance with this common group . In order to be therapeutic
>>and
>> >>to
>> >> >have a successful outcome with more patients it is necessary  for
>> >>therapists
>> >> >themselves to be healthy . Knowledge is one way forward but it has to
>>be
>> >> >said that treating people who have been around the houses, given
>> >>erroneous
>> >> >information and who are often at  their wits end is a thankless task
>> >> >.........
>> >> >
>> >> >all the best to you
>> >> >
>> >> >Ian p.s I am looking for a new job!
>> >> >
>> >>
>> >
>> >______________________________________________________
>> >Get Your Private, Free Email at http://www.hotmail.com
>> >
>>
>
>______________________________________________________
>Get Your Private, Free Email at http://www.hotmail.com
>



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